Obs and Gynae Flashcards
What is ante-partum haemorrhage?
Bleeding from the genital tract from 24 weeks gestation before the onset of labour
WHat are the causes of ante-partum haemorrhage?
Placenta praevia
Placenta Abruption
Vasa Praevia
Uterine rupture
Varicosities
Polyps
Tumours
Trauma
Ectropian
How do class placenta praevia?
Major
Minor
What is placenta praevia
When the placenta is blocking the opening of the cervix so the baby cannot be delivered vaginally
Symtpms of placenta praevia
Painless
Vaginal bleeding
What are the signs of placenta praevia?
High presenting part
Malpresentation
soft uterus
What do you look for in foetal assessment
Foetal movements
FH Auscultation
CTG
USS
Is a transvaginal USS safe to do if the lady had placenta praevia?
Yes
With any bleed in a pregnant lady, what should you always check?
rhesus status
What happens if the pregnant lady is rhesus negative?
She will require anti-D prophylaxis to prevent haemolytic disease of the newborn
What is placenta abruption?
Placental abruption occurs when the placenta separates from the inner wall of the uterus before birth. Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother. In some cases, early delivery is needed
Classification of placenta abruption?
Concealed
Revealed
Both
Symptoms of placenta abruption?
Abdominal pain
Vaginal Bleeding
Signs of placenta abruption?
Woody hard uterus
Vaginal bleeding
Foetal distress, maternal shock
Post partum harmorrhage is a obesteric emergency
TRUE OR FALSE
TRUE
What is postpartum haemorrhage
Postpartum haemorrhage (PPH) is heavy bleeding after birth. PPH can be primary or secondary: • Primary PPH is when you lose 500 ml (a pint) or more of blood within the. first 24 hours after the birth of your baby.
What is primary postpartum haemorrhage?
When 500mls or more of blood is lost from the genital tract occuring within 24 hours of delivery
Causes of primary PPH?
Tone- refers to a failure of the uterus to contract
Trauma- can be caused by episiotomy, tear, haematoma, uterine inversion or a ruptured uterus.
Tissue - refers to tretained placenta membrane
Thrombin- any coagulation problem.
What is the most common cause of primary PPH?
uterine atony
Tx for pph?
Tone - uterine massage, bimanual compression. Medical and surgical management (iv oxytoxin, uterine sutture,)
Trauma- repair
Tissue- manual removal
Thrombim-Harmatology
What is secondary PPH
an excessive abnormal bleeding from the gential tract from 24 hours to 6 weeks post partum
Causes of secondary PPH
Endometritis
Retained placenta and membranes
Trauma
What are the indication for assisted delivery?
Fetal: distress
Maternal: Exhaustion/ comorbidity i.e neuro/cardiac conditions
Delay in 2nd stage of labour
What instruments can be used for assisted delivery?
Simpsons Forceps
Hand hels suction cup or ventouse
Suction cup
What are some important points you need to know about forceps?
- Need adequate analgesia ie pudendal block/epidural
- Less reliant on maternal effort
- Need to do episiotomy with all forceps to minimize OASI risk
- Always check for vaginal trauma afterwards
- Instrument of choice for preterm infants
- Can rotate infants with forces (in theatre)
What are some important points about ventouse?
- Can be used with pudendal block or local infiltration (if necessary)
- More reliant on maternal effort
- Ensure all equipment correctly assembled and working beforehand
- Positioning of cup important
- Consider episiotomy (in mulliparous women)
- Can’t use on babies <34/40, careful use <36/40 (bleeding risk)
- Warn parents of swelling on babies head- will settle down
Can caesarean section is only elective surgery
TRUE OR FALSE
FALSE
elective and emergency
How ‘to do’ emergencies weel?
- Identify high risk patients and anticipate any potential emergencies
- take steps before hand to reduce the risk if possible
- have appropriatley trained staff caring for woman
- inform patient of increased risks and possibilities
- document well- importance of a scribe
- debrief with patient/relatives/colleagues afterwards
- always ask for help, early
If the babys head is delivered but finding it hard to deliver the shoulders of the baby, what is the likely diagnoses?
Shoulder dystocia
What is shoulder dystocia?
Failure of head to deliver despite maternal effort and normal traction of head
- the anterior shoulder impacts behind the pubic symphysis
- disimpaction will lead to delivery
- can cause compression of cord
- risk of brachial plexus injury
In an obsteric emergency (shoulder dystocia) what is a good acronym to remember?
HELPERR
Help- emergency buzzer
Episiotomy- evaluate for this to make more room for maneuvers
Legs- Mc Roberts position
Pressure- constant then rocking suprpubic behind anterior shoulder
Enter- finger behinf anterior shoulder, behind post shoulder, Wood screw amneuver
Remove- posterior arm grabbed
Roll- onto all fours and repeat
What can be the complications with shoulder dystocia?
brachial plexus injury
erbs palsy specifically
What is cord prolapse?
- Immediate delivery via C/S- unless fully dilated and delivery imminent, could consider del in room with instrument
- minimal handling of loops of cord
- manually elevate the presenting part off cord or fill urinary bladder
- mum in knee- chest position
- consider tocolysis - if delivery is delayed
What is eclampsia?
Eclampsia is the new onset of seizures or coma in a pregnant woman with preeclampsia. These seizures are not related to an existing brain condition
Mx for eclampsia?
- call for help
- ABCDE
- Loading dose MgSO2 (50% strength) 1g/hour infusoin for 24 hours since last seizure
- Monitor closely- HDU setting
- 10min observation/ hourly urine output/reflexes
- Magnesium Toxicity (poor UO <25ml/hour, absent reflexes, RR<14, Sats<90%)
- Consider Calciu Gluconate 10ml 10% IV
- Treat high BP- IV infusion vs oral medication (labetalol 1st line) Amin <150/100
- Fluid restrict (80ml/hour)- Renal failure and pulmonary oedema
- Repeat bloods also
- HELLP syndrome
- Experdite delivery
What is abnormal uterine bleeding? AUB
Bleeding from the uterine corpus that is abnormal in duration, volume, frequency, and/or regularity
What is the classification used for abnormla uterine bleeding?
FIGO CLassifciation
What is always classed is abnormal uterine bleeding?
Intermenstrual bleeding (cyclical or random)
Unschedules bleeding on hormone medication
WHat are the causes fo AUB
- *P**olyps
- *A**denolyosis
- *L**eimoyoma
- *M**alignancy
- *C**oagulopathy
- *O**vulatory
- *E**ndometrial
- *I**atrogenic
- *N**ot yet classified
What are the medical and surgical managements for heavy menstral bleeding
What does the infectious diseases screening programme screen for?
Hepatitis B
HIV
Syphillis
When should screening be performed for antenatals
screenign should ideally be performed as early as possible in pregancy but can be performed up to and including labour
What do you test in antenatal screening for infectious disease?
Materanl serum sample
What is urinary incontinence?
Involuntary leakage of urine
What is the difference between stress, urge and mixed urinary incontinence?
Stress UI; Incontinence on effort or physical exertion or on sneezing or coughing
Urge UI: incontinence associated with urgency
Mixed UI: UI associated with urgency and also with effort or physical exertion or on sneezing ot coughing
What trigger could cause urinary incontinence?
Cough
Exercise
Intercourse
Urge to PU
Nocturia
coffee
tea
alcohol
fizzy drinks
WHat is intialy treatment for UI
conservative
lifestyle modification including weightloss to keep BMI<30 and fluid adjustment and avoiding caffeine.
behaviour modication with bladder training for at least 6 weeks
Supervised pelvic floor exercises for at least 3 months
Drugs used for Urge (UI)
Anticholinergics
If not tolerant can try mirabegron
WHat are the side effects of anticholinergics?
be wary of giving oxybutynin to elderly women due to risk of dementia
Investigations for urge incontinence?
Urodynamics: may help to determine flow pattern and confirm stress or detrusor overactibity, If confirmed DO non responsive to medication
WHat is the next step if detrusor overactivity is confirmed?
Cystoscopic injection of Botulim Toxin A (Botox) to the bladder wall. Start with 100IU
Sacral Nerve stimulation
If all fails:
Augmentation cystoplasy
Urinary Diversion
Treatment options for stress incontinence?
Colposuspension: Open or laproscopic
Autologous fascial sling
(Mid urethral mesh sling)
Inramural bulking agent
follow up in 6 months
What is pop-q classification?
The Pelvic Organ Prolapse Quantifications System (POP-Q) is a system for assessing the degree of prolapse of pelvic organs to help standardize diagnosing, comparing, documenting, and sharing of clinical findings.
Treatment for pelvic floor prolapse?
Based on patients desire
stage 1 and stage 2: 16 weeks supervised PFE
-Vaginal oestrogen for atrophic tissue
Vaginal pessaries
surgery based on compartment involved
When should nausea and vomiting be diagnosed in pregnancy?
when onsent is in the first trimester and toher causes of nausea and vomitting have been excluded
if it is after 10 weeks of gestation then other csauses need to be considered
What is hyoeremesis gravidarum?
Some pregnant women experience very bad nausea and vomiting. They might be sick many times a day and be unable to keep food or drink down, which can impact on their daily life. This excessive nausea and vomiting is known as hyperemesis gravidarum (HG), and often needs hospital treatment.
How is hyperemesis gravidarum diagnosed in pregnancy?
When there is protracted nauseas and vomiting with the traid of more than 5% of pre-preganncy weight loss, dehydration and electrolyte imbalance.
How can the severity of nausea and vomitting be classified?
PUQE score
pregnancy-unique quantification of emesis and nausea
Ix for nausea and vomitting?
History - exclude H. pylori
Exam
PUQE score
Urinary dipstick
Electrolytes
FBC
Blood glucose
USS
LFTs
TFTs
What are the differential diagnosis when we see apatient with nausea and vomiting in patients?
peptic ulcers
cholecystitis
gastroenterisits,
hepatitis pancreatits
genitourinary condition : UTI, pyelonephritis
metabolic conditions
Neurological
drug induced
Gastrodudenoscopy considered safe in pregnancy?
Yes
What is the inital management for people with nausea and vomitting?
oral anti-emetics
Not tolerated then parenteral fluid, parenteral vitmains, multi and b complex vitamins
Subcutaneous metoclopramide therapy
Theraputic options for nausea and vomittting in pregnancy?
Anti histamines
Phenothiazines
H2 receptor antagonists
